Covering the World of Communication Sciences and Disorders

SIGnatures: Evolving Expressions of Culture

Providing effective treatment requires that clinicians constantly work to understand clients' many cultures, and to question assumptions not just about gender, race and ethnicity, but also about age and life stage.

Special Interest Group 15, Gerontology

by
Luis F. Riquelme

see also

How many cultures do you belong to? A hospital-based
speech-language pathologist may belong to many: the group of professionals that
works with adults with neurological impairments and communication and
swallowing disorders; the group that carries specialization and board recognition
in swallowing; the group that works in acute-care hospitals; the group that
likes to dance socially; the group that likes to drink alcohol socially; the
group that likes to eat out at a variety of restaurants; the group that enjoys
travel; the group that enjoys kayaking; the group that enjoys entertaining for
dinner parties; the group that enjoys dressing well; the group that believes in
being there for family; the group that believes in helping others; the group
that likes the color purple; the group that loves a person of the same gender;
the group that enjoys the beach; and the group that enjoys concerts in the
park. This person alone is part of 16 different groups, or cultures.

How are we, as care providers, supposed to know about all
the cultural groups of this colleague, not to mention those of our patients,
clients and students?

To start—if we are to be responsible members of our society
and discipline—it is vital that we understand, apply and believe in concepts of
culture (see box on page 53) and their impact on everything we do as people and
professionals. Unless we genuinely care for and show interest in people, the
treatment process may break down and result in misdiagnosis or negatively
influence treatment outcomes.

How can sociocultural mismatches compromise the
provider-patient dynamic? First, the provider may lack knowledge about the
patient's health beliefs and life experiences, as Melanie Tervalon and Jann
Murray-Garcia noted in their 1998 article, "Cultural Humility Versus Cultural
Competence," in the Journal of Health Care for the Poor and Underserved.
Second, the provider may bring unintentional or intentional processes of
racism, classism, homophobia or sexism to the interaction. Thus, according to
Tervalon and Murray-Garcia, no clinician can expect to achieve cultural
competence as a discrete endpoint. Instead, cultural competence is a lifelong
commitment to learning, constantly working to bridge cultural gaps and
questioning cultural assumptions.

But this assertion brings us back to the central question:
How can we be culturally competent if everyone around us is a part of many
dynamic and ever-changing cultures? For example, when does a patient enter the
culture of "older adults"? In American society, this group may be defined by
chronological age—namely, turning 65. However, many 70-year-olds do not
consider themselves "old." So, the "older adult" culture is defined by the
people identifying with that label and not by the imposition of a particular
government-defined age.

Another way to view this concept is the fact that people
like and dislike things throughout the continuum of life. A person who was
included in the "lovers of loud music" culture 10 years ago may not enjoy loud
music any longer, and so is not a member of that culture. We may view a
person's culture, then, as dynamic and evolving, continuously changing based on
preferences and life experiences.

The client's perspective

So far, this discussion has focused on the practitioner and
the practice of caring for someone, but what about the perspective of the
person being cared for? Some argue that cultural competence is a bilateral
process; others argue it is not. In his 2008 article in the Online Journal of
Health Ethics, Carlos Alberto Sánchez presented an argument against the
bilaterality of cultural competence. He argued—based on John Rawls' "difference
principle"—that the patient is not necessarily empowered to expect culturally
competent services.

The patient's perspective or expectation varies by
ethnicity, socioeconomic status, prior experience, setting or other possible
factors. Take, for example, a clinician who meets a client for the first
evaluation session and immediately begins to ask questions, so as to quickly
complete the interview and record all necessary historical information. The
clinician then goes on to test the client, and subsequently bids him or her
farewell. But note that the clinician hasn't allowed the client to voice his or
her concerns and perspectives regarding communication and swallowing. Has the
clinician gleaned a sense of this problem's impact on the client's life? Did
the clinician assume that the patient was aware of the diagnostic process? Did
stereotyping on the part of the clinician influence this session? Did the
clinician assume that because the patient was older, that maybe he or she
expected to develop a communication or swallowing disorder?

Cultural competence: How to get there

Be aware of ethnocentrism, the belief that one's way of life
and view of the world are inherently superior to others and more desirable.
Ethnocentrism in health care may prevent professionals from working effectively
with a patient whose beliefs or culture does not match their own worldview. An
ethnocentric care provider or client may hinder the processes of assessment,
treatment or management of a communication or swallowing disorder. An example
of ethnocentrism is the clinician who can see only his or her recommended
treatment plan and does not entertain other options presented—if allowed—by the
patient/client.

Be aware of essentialism, which defines groups as
"essentially" different, with characteristics "natural" to a group.
Essentialism does not take into account variation within a culture, and can
lead health care professionals to stereotype their patients. The clinical
practice of an essentialist focuses on beliefs about groups instead of
observations of individuals. This situation is disadvantageous to the
practitioner and the client. The essentialist viewpoint needs to be replaced
with an ethnogenetic one, which recognizes that groups, cultures and the
individuals within them are fluid and complex in their identities and
relationships. An example would be any situation in which the practitioner
automatically identifies a person as being a part of a group without obtaining
confirmation.

Be aware of power differences that reflect an imbalance in
client-provider relationships. Interestingly, those with power often are not
aware of its daily effects. Some ethnic groups may feel powerless when faced
with institutionalized racism and other forms of privilege enjoyed by the
dominant group. Examples of this imbalance may include the patient's perception
that the clinician has all the answers, or a sense of the clinician's
superiority due to his or her advanced education. Tervalon and Murray-Garcia
refer to power differences in their discussion of cultural humility: Without
knowing about power differences and their effects, health care professionals
can perpetuate health disparities.

Although one frequently thinks of a patient as being from a
different ethnicity or race, these concepts apply to all cultural groups,
including people older than 65. This age group may feel vulnerable for many
social and economic reasons, as indicated in a 2002 study looking at healthy
aging and expectations from older adults.

Conducted by Catherine A. Sarkisian, Ron D. Hays and Carol
M. Mangione and published in the Journal of the American Geriatrics Society,
the study found that, "More than 50 percent of participants felt it was an
expected part of aging to become depressed, to become more dependent, to have
more aches and pains, to have less ability to have sex, and to have less energy."
The sample consisted of 429 randomly selected community-residing adults age 65
to 100 (mean age 76). After adjusting for sociodemographic and health
characteristics using multivariate regression, the authors found that older age
was independently associated with lower expectations regarding aging, as was
having lower physical and mental health-related quality of life. Moreover,
having lower expectations regarding aging was independently associated with
placing less importance on seeking health care.

Clinicians, in reflecting on the broadness of cultural
diversity at a personal and professional level, may ask, "How do I achieve
cultural competence?" There is no set formula, but there are several readily
available strategies and tools:

Develop a definition of what constitutes culture that is
comfortable for you. We should think of it as a "living definition" to allow
for possible change, or redefinition, as we grow.

Consider the concept of cultural humility and accept that
becoming culturally sensitive and competent is a lifelong process.

Recognize our own implicit biases, stereotypes
and possibly racist notions. These may be thoughts or feelings we wish to deny,
but must accept to work through them (see "Not All Bias Is Obvious—Even Our Own", and the Implicit Association Test). Some are not as clear as
others, and through our cultural awareness, we may discover them. Once these
biases are at the surface of our thoughts, we can work through them.

Use ethnographic interviewing techniques, introduced by
Carol Westby. A clinician employing this process draws out behaviors and
beliefs from the patient or caregiver through a systematic and guided dialogue.
(See "Asking the Right Questions in the Right Ways," The ASHA Leader, April 29,
2003)

Once we are comfortable that becoming culturally competent
is a lifelong process, we can further develop the tools we have, as we search
for others. But will we ever be fully culturally competent? I do not think so.
We may, however, strive to become culturally aware and engage in the lifelong
process of learning and exploration regarding the cultures of the many groups
to which we all belong.

This article is adapted from "Cultural Competence for
Everyone: A Shift in Perspectives," in the May 2013 issue of SIG 15's
Perspectives on Gerontology.

Luis F. Riquelme,
PhD, CCC-SLP, BRS-S,
is an associate professor of speech-language pathology at New York Medical College and director of Barrique SLP at New York Methodist Hospital in Brooklyn. He is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; 13, Swallowing and Swallowing Disorders (Dysphagia); 14, Communication Sciences and Disorders in Culturally and Linguistically Diverse Populations; 15, Gerontology; and 17, Global Issues in Communication Sciences and Related Disorders.
luis_riquelme@nymc.edu

Sources

American Speech-Language-Hearing Association. (2004).
Knowledge and skills needed by speech-language pathologists and audiologists to
provide culturally and linguistically appropriate services [Knowledge and
Skills]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2005).
Cultural competence [Issues in Ethics]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2011).
Cultural competence in professional service delivery [Professional Issues
Statement]. Available from www.asha.org/policy/.

U.S. Department of Health and Human Services, Office of
Minority Health. (2001). National standards for culturally and linguistically
appropriate services in health care: Final report. Retrieved from
https://minorityhealth.hhs.gov/clas.

Westby, C., Burda, A., & Mehta, Z. (2003, April 29).
Asking the right questions in the right ways: Strategies for ethnographic
interviewing. The ASHA Leader.

Westby, C. (1990). Ethnographic interviewing: Asking the
right questions to the right people in the right ways. Communication Disorders
Quarterly, 13(1), 101–111. doi: 10.1177/152574019001300111.

Culture:
What's it all about?

"Culture" refers to integrated patterns of human behavior that
include language, thoughts, communications, actions, customs,
beliefs, values and institutions of racial, ethnic, religious or
social groups, according to the U.S. Department of Health and Human
Services' definition. Culture goes beyond race and ethnicity, and
it is up to the practitioner to define culture more broadly and
include religious beliefs, lifestyles, special interests—even
choice of supermarkets.